Federal officials work to reverse Education Dept.'s new formula for rural-school program, which would cut budgets

Sens. Lamar Alexander of Tennessee and Susan Collins of Maine and others in Congress are working on a fast reversal of the U.S. Department of Education's new formula that sends less money to hundreds of rural school districts, Erica Green reports for The New York Times.

The department's change, reported Feb. 14 by Education Week and Feb. 17 by The Rural Blog, "alarmed lawmakers and advocates who questioned why an administration whose political base includes large sections of rural America would initiate such a change — especially in an election year," Green writes. "Rural school districts, which serve nearly one in seven public-school students, have long been considered the most underfunded and ignored in the country."

Rural schools have several sources of federal money, but the only program specifically targeted to them is the Rural Education Achievement Program, created in 2002. That law says districts "must use data from the Census Bureau’s Small Area Income and Poverty Estimates to determine whether 20 percent of their area’s school-age children live below the poverty line," Green notes. "For about 17 years though, the department has allowed schools to use the percentage of students who qualify for federally subsidized free and reduced-price meals, a common proxy for school poverty rates, because census data can miss residents in rural areas."

That can make for a big difference. "In Oklahoma, which will see the number of eligible schools cut nearly in half, Matt Holder, the superintendent of Sulphur Public Schools, said the $30,000 cut to his 1,500-student district would cost him a reading specialist in his elementary school," Green writes. "In a district where 60 percent of students live in poverty, literacy is a ladder to opportunity, he said."

The Education Department seems to be going along with the congressional fix. Its officials "said they were surprised to discover that the law had not been followed for more than a decade, and agreed that census data was not the right metric to determine eligibility for the program," Green reports.

USDA develops test strip for the type of toxin that causes 90% of sickness and deaths from eating wild mushrooms

Bureau of Land Management photo, via The Counter

The U.S. Department of Agriculture has developed "a simple test strip" that can tell you if a wild mushroom has the type of toxin that is responsible for 90 percent of the illnesses and deaths caused by eating the wild fungi, Jessica Fu reports for The Counter, which says it covers "fact and friction in American food." (It was once known as The New Food Economy.)

Candace Bever, a USDA scientist who worked on developing
the test strip, took a selfie with a "death cap" mushroom.

More than 6,300 Americans got sick from eating toxic mushrooms in 2018, according to the National Poison Data System, Fu reports: "Without immediate treatment, consuming poisonous species can lead to liver damage and even death. And among mushroom-related deaths, medical experts have estimated that around 90 percent are linked to a specific category of toxins known as amatoxins."

The strip developed by USDA scientists "can detect the presence of amatoxins found in wild mushrooms in a matter of minutes—a tool they hope can help foragers avoid food poisoning," Fu writes. "The new technology . . . can detect the common toxins in both urine and mushroom samples at concentrations as low as 10 parts per billion." USDA researcher Candace Bever and her colleagues published their findings in Toxins, a peer-reviewed scientific journal.

Urine samples can be used by people who get sick after eating mushrooms but no longer have a sample of them. "The long tail of mushroom toxicity gives eaters time to seek medical help, which can be a matter of life and death," Fu explains. The strip can also work on dog urine. "Man’s best friends are a common victim of toxic mushrooms, which they can accidentally eat when roaming outdoors," and are more susceptible to poisoning than humans, and die more quickly, Fu reports.

"You might be wondering when you can buy these mushroom test strips," Fu writes. "Bever tells me that a company named Amatoxtest is already in the process of licensing USDA’s technology for a product expected to hit shelves this coming autumn."

Study: Rural women with ovarian cancer more likely to be diagnosed at Stage IV, but not because of distance to doctor

Rural women who have ovarian cancer are more likely to find out about it when it's already at stage IV than women who live in metropolitan areas, according to a study in The Journal of Rural Health. That matters because detecting cancer earlier makes for a higher survival rate. From 2000 to 2015, the five-year survival rate of stage IV ovarian cancer was only 29 percent. The American Cancer Society estimates that 23,000 women were diagnosed with ovarian cancer in 2019, and about 14,000 died or will die from it.

Researchers from the University of Iowa and the Centers for Disease Control and Prevention studied a sample of about 1,000 women in Iowa, Kansas and Missouri who had been diagnosed with ovarian cancer in 2011-2012. At the time of diagnosis, 111 had stage IV and 889 had stages I-III. The stage IV patients were more likely to be older, rural, and have other health problems.

It is tempting to attribute that difference to poverty, or difficulty in accessing health care, but the study controlled for those factors. Rural women were more likely to be diagnosed with late-stage ovarian cancer regardless of their census tract's socioeconomic status or the distance to their primary care provider.

The diagnosis-stage disparity also isn't likely related to lifestyle factors such as smoking, obesity, or lack of physical activity; though such factors are more prevalent in rural areas, they aren't prominent risk factors for ovarian cancer. And though it's possible those lifestyle factors could create a higher incidence of cancer, they aren't likely to create geographic survival or diagnostic disparities.

Rural cancer patients overall have poorer outcomes than non-rural patients, including a lower survival rate. That's true of rural ovarian cancer patients too, probably because of lower access to specialty care and treatment after diagnosis.

The researchers suggest that better access to gynecological specialists in urban areas could make a difference, since those doctors are highly trained and may be able to recognize the symptoms of ovarian cancer sooner than other health care providers.

S.C. primary 'a fight on back roads and in small towns over who appeals to rural and black voters' and gets their issues

UPDATE: Joe Biden got about half the overall vote, better than expected. In the exit poll, he got 56 percent of the rural vote (which accounted for 41 percent of the sample) and 61 percent of the African American vote (which was 57 percent of the sample).

South Carolina's black population skews rural. (Rural Policy Research Institute)

South Carolina's presidential primary today is "a fight on back roads and in small towns over who appeals to rural and black voters and who really understands their issues," Lisa DesJardins reports for the PBS NewsHour.

At the 2010 census, South Carolina's population was about 34 percent rural and 29 percent African American. But most South Carolina Democrats are black, and so are most South Carolinians who live in "non-core" counties, those without a city of 10,000 or more.

But some rural African Americans told Trymaine Lee of MSNBC that the candidates haven't paid enough attention to the state's rural areas. "They feel left out, they feel abandoned," Lee said in a report Friday. One man in Eadytown told him, "They don't think . . . of us out here in the country."

DesJardins says the fight in South Carolina is between former vice president Joe Biden, Vermont Sen. Bernie Sanders and billionaire Tom Steyer, whose rural and black support gives him hope of beating out Sanders for second place. Biden is favored, following a good debate performance and the endorsement of U.S. Rep. Jim Clyburn, who as House majority whip is the nation's highest-ranking federal politician.

Biden long ago called South Carolina his "firewall" because of the African American support he earned from eight years in the White House with the nation's first black president. However, "Black voters here aren't particularly enthused about their options," The Washington Post reports, introducing a deep dive by reporter Vanessa Williams on Wadmalaw Island south of Charleston. The Post also has a video story by Kate Woodsome and Joy Sharon Yi, featuring black South Carolinians who say they have a lot more immediate concerns than the presidential election.

Harold McClain, who was a student protester in the 1960s, told DesJardins that he trusts Biden as a unifier, and thinks Sanders goes too far, but he indicated that the black vote is up for grabs: "Contrary to popular belief, we're a pretty diverse voting bloc."

The Post notes, "South Carolina doesn’t have partisan voter registration, which means Saturday’s Democratic primary is open to everyone. A sizable swath of the electorate will therefore be moderate-minded independents who are uncomfortable with Sanders’s revolutionary rhetoric."

On the NewsHour's political-analysis segment Friday night, New York Times columnist David Brooks said it will be interesting to see how many black votes Sanders can get. As for Biden, "If he has a 10-point win, he can stay afloat" until March 3, Super Tuesday, when 14 states vote. But they noted that Biden is so short of money that he is not running TV ads in those states.

Ignoring rural people hurt by extreme weather also means ignoring impact of climate change, Appalachian author says

Silas House (Berea College photo)

Near-record flooding in the first two weeks of February damaged or destroyed more than 300 homes and caused at least one death in Central Appalachia, but it barely made a blip on the nationwide news. That's unsurprising, writes Kentucky author Silas House for The Atlantic: "When trouble comes to rural people—whether they’re in Kentucky, California, Montana, or Michigan—the media mostly shrug. The public as a whole is no better, as people seem to have little sympathy for these rural areas."

Many question why someone would want to live in a rural area in the first place, House writes, noting that, in 2017, President Trump told unemployed people in New York state that their best bet would be to move to a city. But community is important to people in rural areas, and so is place: "My parents, and many other people where I am from, say they need night skies undimmed by city lights. They cannot breathe properly in places that lack hills and pastures. Their native topography is in their blood and bones," House writes.

Because of they're more connected to nature, rural people are uniquely placed to see the impact of policy on our environment. "If coal mining isn’t devouring the mountain in front of your house, then it’s easy to leave all the lights on. If your home isn’t being carried away by floodwaters, it’s hard to feel the consequences of climate change," House writes. That doesn't stop many from voting for politicians like Trump who "value profit over the environment," but it's complicated, he writes.

Rural people often feel overlooked and judged by urban residents, and the news media have a long history of perpetuating rural stereotypes, House writes: "Americans claim to love the natural world, but we often negate the people who live closest to it. Insulting phrases like the middle of nowhere and flyover country are common parlance in everyday conversations and newscasts. Besides being irritating, the stereotype of rural people as inferior and separate has also allowed Americans to take the effects of climate change in this area less seriously, to let the devastation slip by unnoticed. By turning a blind eye to rural people, we are turning a blind eye to climate change."

USDA will let hemp farmers destroy 'hot' crops themselves, but stands by 15-day rule; DEA allows more labs to do tests

Hemp farmers whose crop is found too much of the psychoactive ingredient that makes it marijuana will be allowed to destroy the fields themselves instead of hiring contractors, the U.S. Department of Agriculture said Wednesday. USDA also plans to "expand the number of laboratories that can test industrial hemp for THC levels," Chuck Abbott reports for Successful Farming.

"Growers and state officials have complained that there will not be enough laboratories to test hemp samples when harvest time arrives and that farmers could be saddled with the high cost of destroying fields of hemp that exceed the THC limit," making them "hot," Abbott writes. "The USDA interim rule issued last fall also said that when fields exceed the THC limit, the crop would be disposed of by law enforcement or a DEA-approved 'reverse distributor,' who would treat hemp with the same protocols as contraband drugs, such as incineration."

Agriculture Undersecretary Greg Ibach said that after discussions with the Drug Enforcement Administration, testing labs won't have to complete a DEA certification process this year, so they test for THC if states consider them reliable.

"Ibach did not mention another complaint of growers: the requirement to harvest a field within 15 days of collecting samples for THC tests," Abbott reports. "Producers say 15 days is not enough time to get a report from a test lab and then harvest the field." The rule is part of rules that USDA issued in October that are more rigorous than those used in many states' pilot hemp programs.

Quick hits: Rural military enrollment factoid debunked; lack of data makes it hard to improve prisons

Here's a roundup of stories with rural resonance; if you do or see similar work that should be shared on The Rural Blog, email us at heather.chapman@uky.edu.

For years, a false factoid has been making the rounds that rural Americans make up 44 percent of the military. The latest person to repeat it was the CEO of a major agricultural cooperative. But the real figure is more like 20%, writes Tim Marema of The Daily Yonder.

A Report for America journalist, who was assigned to cover poverty in her hometown of Charleston, W.Va., says poverty and its causes are more nuanced than the data often suggest — and says she sees signs of hope. Read more here.

A University of Kentucky nutrition professor discusses in a podcast how she is working to eliminate food deserts in rural Kentucky. Read more here.

The nation's prisons and jails face major challenges, but a lack of reliable data makes it harder to know how to improve things. Read more here.

The American Civil Liberties Union has filed a lawsuit against seven small Texas towns that declared themselves abortion sanctuary cities. Read more here.

Under change in Kentucky law, fewer coal miners qualify for black-lung benefits

In March of 2018, Kentucky enacted a law that opponents feared would make it harder for miners to get compensation for black-lung disease. A review of state records shows that the share of Kentucky miners "diagnosed by state-approved experts as having the disease fell from 54 percent before the law change to just 26 percent," Sydney Boles reports for Ohio Valley ReSource, a public-radio consortium. "An analysis of state data by the Ohio Valley ReSource also suggests that the doctors now making decisions on claims more often side with coal companies than with coal miners."

To get black-lung benefits, a miner or family member files a claim with the state Labor Cabinet that includes evidence of diagnosis: a blood-gas analysis showing breathing impairment, and an X-ray showing evidence of black lung. "Once the claim is filed, the miner’s most recent employer’s insurance company can request to have an X-ray read by a physician of their choosing, and the judge overseeing the case can require a third reading from a 'designated evaluator,' whose analysis is presumed to be correct unless there is overwhelming evidence to the contrary," Boles reports.

Before the law was passed, radiologists were allowed to diagnose black lung, since evaluating X-rays is their specialty. But under the new law, only certain pulmonologists, doctors who specialize in the lungs, are allowed to diagnose it, Boles reports. At the time the law was passed, only six Kentucky pulmonologists had the federal certification to diagnose black lung, and four of them were routinely hired by coal companies or their insurers, Howard Berkes of NPR and Benny Becker of OVR reported at the time. The law also excluded out-of-state doctors from diagnosing the disease.

Only two pulmonologists, both with ties to the coal industry, chose to serve as designated evaluators. Data showed that both disagreed with an initial black lung diagnosis in 85.5% of cases, Boles reports.

"The changes to state law have not resulted in a backlog of cases, as opponents had feared. But state records indicate that the restrictions have had an impact on the share of miners who win their claims," Boles reports. "The ReSource found that 161 benefits claims were filed but only 16 coal miners were awarded black lung benefits in 2019. That’s the lowest ratio of claims awarded to claims dismissed in the past seven years." Boles notes that not all claims are resolved in the same calendar year in which they are filed.

Interior resumes federal coal sales, proposes rule to restrict the types of studies it can use in making decisions

"The Trump administration said Wednesday a resumption of coal sales from public lands that had been blocked under former President Barack Obama will result in a negligible increase in greenhouse gas emissions," reports Matthew Brown of The Associated Press. "Critics accused the administration of producing a flawed analysis of the federal coal program that ignores its broader impacts."

The Obama-era Interior Department banned most federal coal sales in 2016. Former Interior Secretary Ryan Zinke lifted the moratorium in 2017, but in April 2019, a federal judge ruled that the Trump administration had failed to consider potential damage to the environment in making that decision, and told Interior to conduct an environmental review of its decision, Brown reports.

"The Trump administration review focused on potential emissions from only four coal leases in Utah and Oklahoma that were sold after the moratorium was lifted," Brown reports. "That’s a small piece of a federal leasing program that accounts for about about 40 percent of U.S. coal production, primarily from Western states that also include Wyoming, Montana and Colorado. Burning that fuel accounts for about 11 percent of annual U.S. greenhouse-gas emissions.

The resumption of coal sales coincides with another Interior proposal to limit scientific studies that can be considered in making decisions. Under the plan, the agency could not consider studies that don't make all of their underlying data public, Rebecca Beitsch reports for The Hill.

"Critics argue that the move, described by the agency as an effort to increase transparency, would sideline landmark scientific research, particularly in cases where revealing such data would result in privacy violations," Beitsch reports. "The proposal, dubbed the Promoting Open Science rule, mirrors a similar effort at the Environmental Protection Agency, which critics argue would block that agency from considering renowned public-health studies."

Interior says the new rule would ensure that it uses only the most reliable data, but Andrew Rosenberg of the Union of Concerned Scientists told Beitsch it's meant to stifle science: "It doesn't do anything to help transparency. It’s designed to restrict the science the agency can use."

Journalism with rural resonance gets several nominations in Scripps Howard Awards; winners to be named March 3

Climate change, investigative journalism and newsroom collaborations were frequent themes in the 2019 Scripps Howard Awards finalists announced this week, Rebecca Cochran reports. Several nominees had rural resonance; in the Community Journalism category, all three warrant mention.

Troubled Kids, Troubled System, from the Missoulian in Montana, examines reform schools in rural areas that often operate with little oversight. Some former students say teens were physically and sexually abused, and some teens died by suicide at the schools. The for-profit schools, which sometimes charge parents more than $100,000 a year, often are not overseen by mental-health, child-safety or education experts. None of the 58 complaints investigated by the state have resulted in significant disciplinary action against any program.

The Anchorage Daily News partnered with ProPublica's Local Reporting Network to produce Lawless, a series that uncovered a sexual assault crisis in rural Alaska and how the lack of public-safety services makes it worse. After the series ran, U.S. Attorney General William Bar declared the lack of law enforcement in rural Alaska a federal emergency, and the Department of Justice has promised more than $52 million in federal funding to improve the situation. The U.S. attorney in Anchorage also announced the hiring of additional rural prosecutors, and Gov. Mike Dunleavy said the state will hire 15 additional state troopers.

The other Community Journalism nominee was MLK50, a Memphis non-profit reporting on economic justice, worked with ProPublica to produce Profiting from the Poor, a series that made the area's largest hospital system stop its aggressive pursuit of the poor (including its employees) for unpaid bills, forgive nearly $12 million in debt and made discounted or free care easier to get.

In the Investigative Reporting category, the Houston Chronicle and San Antonio Express-News were nominated for their Abuse of Faith package, which put the Southern Baptist Convention under the spotlight for not adequately dealing with allegations of sexual abuse. As part of the package, they published a searchable database of church officials and volunteers who had been convicted of sex crimes or made plea deals with prosecutors.

Partial screenshot of Washington Post story by Eli Saslow

The Washington Post was nominated in the Human Interest Storytelling category for The State of Health Care in Rural America, which illustrated the dire situation of rural health care through Eli Saslow's story of a struggling hospital in Oklahoma.

The Post received seven nominations, the most of any news outlet. In the Multimedia category, it was nominated for its Gone in a Generation piece, which explored how global warming is already changing Americans' lives, including farmers, hunters, and those who live in flood zones.

In the Environmental Reporting category, What Can Be Saved? by The Associated Press was nominated for its wide-ranging reporting on the impact of climate change, including in Everglades National Park. Also nominated was The Oregonian's Polluted by Money, which explored how corporate lobbying has weakened or halted state efforts to deal with environmental issues such as climate change, disappearing bird habitats, carcinogenic diesel exhaust, industrial air pollution, oil spill planning, and pesticides sprayed from helicopters.

One Disaster Away, about insufficient protections for vulnerable people as climate change worsens natural disasters, was nominated in the Topic of the Year category, The Impact of Climate Change on Communities. The series is a partnership between The Center for Public Integrity, the Atlanta Journal-Constitution, High Country News, Ohio Valley ReSource (a public radio consortium in Kentucky, Ohio and West Virginia) and StateImpact Oklahoma.

In the Distinguished Service to the First Amendment category, the Orlando Sentinel scored a nomination for its Florida's Fading Sunshine Laws package.

The winners will be announced March 3. The Scripps Howard Foundation, the philanthropic arm of E.W. Scripps Co., will present more than $170,000 in prize money to the winners on April 16 in Cincinnati. The awards program will be rebroadcast April 26 on Newsy and on Scripps television stations throughout the summer.

Nine senators, including two Republicans, write open letter to USDA, demanding more funding for rural broadband

A bipartisan group of nine senators wrote an open letter to Agriculture Secretary Sonny Perdue on Wednesday, urging the U.S. Department of Agriculture to make more communities eligible to receive funding from ReConnect, its $500 million rural broadband buildout program.

The senators, led by Ron Wyden, D-Ore., accused the USDA of arbitrarily limiting which rural areas are eligible to receive funds. "As it stands, the USDA program says certain rural areas cannot qualify for the fund if they previously received money from the Federal Communications Commission for satellite service," Emily Birnbaum reports for The Hill. "But the senators say satellite service is not enough to fix the issue of the 'digital divide,' and the USDA's funds could have life-saving impacts for areas that do not have good Internet access."

Other signatories were Tammy Baldwin, D-Wisc.; John Barrasso, R-Wyoming; Mike Enzi, R-Wyoming; Doug Jones, D-Ala.; Angus King, I-Maine; Jeff Merkley, D-Ore.; Patty Murray, D-Wash.; and Tom Udall, D-N.M.

The program will provide up to $200 million in grants, $200 million in low-interest loans, and up to $200 million for loan/grant combinations. A second round of ReConnect funding began accepting applications on Jan. 31; applications must be submitted by March 16.

An aging America could present problems for rural areas

"The nation’s population is growing older, posing financial and economic challenges for states around the U.S. in the years ahead, a credit rating agency cautioned this week," Bill Lucia reports for Route Fifty. "S&P Global Ratings notes in a brief that by 2035 the Census Bureau projects the number of people aged 65 and older will outnumber those under 18 for the first time in the nation’s history."

Too many seniors who need Medicare, Social Security, and sometimes Medicaid, combined with not enough younger working people to pay into those systems, could cause a lot of pain for state and federal budgets, Lucia reports. The problem will be especially acute for rural areas, which already have older populations.

"More births and greater in-migration of young people from foreign countries could act as counterweights to the aging population, but are not on pace to do so at current levels," Lucia reports.

USDA's Economic Research Service missing 2/3 of staff after agency move; could hamper agricultural lawmaking

"The Economic Research Service is missing nearly two out of every three employees after Agriculture Secretary Sonny Perdue uprooted the agency from Washington to Kansas City last year," Ryan McCrimmon reports for Politico. "The extensive vacancies are derailing vital research and demoralizing the skeleton crew of workers at the new offices."

Five months later, only 41 of 233 positions at the new offices have been filled, according to an internal USDA memo. "Current and former staff describe a bleak atmosphere at ERS, which publishes scientific research on farming, trade, nutrition, rural economics, the environment and more," McCrimmon reports. "USDA officials say they’re mounting a vigorous hiring process — but in the meantime, there’s a daunting shortage of institutional knowledge at the agency."

That's important because farmers, commodity traders and lawmakers who write ag policy often rely on ERS reports. Employees say the staffing shortages have hampered production of studies, but a USDA spokesperson said the ERS has published all reports on time and said its research output is comparable to 2018. "But researchers disputed that characterization, arguing that many of the studies being published now have been in the works since before the relocation," McCrimmon reports.

'Bear Whisperer' protects a California forest town from bears, sometimes with unconventional methods

Steve Searles patrols the woods near Mammoth Lakes, California. (Los Anegles Times photo by Brian van der Brug)

Mammoth Lakes, California, is a small ski town near the Nevada border, surrounded by forests. That means plenty of bears that could scare off tourists. Some towns seek to control the bear population by killing them, but Mammoth Lakes' wildlife specialist, Steve Searles, has found non-violent ways of containing them, Chris Erskine reports for the Los Angeles Times.

His unorthodox methods, which include stern voice commands and making sure locals don't give the bears any food, have brought down the bear population and earned Searles an Animal Planet show, Erskine reports. Read more here.

Climate change has reduced Colorado River's flow by 1/5, and federal researchers say the trend is likely to continue

U.S. Bureau of Reclamation map; for a larger version, click on it.

The flow of the Colorado River, which is essential to life in the desert Southwest, has declined more than 20 percent because a warming climate is making snowpack evaporate instead of run off, U.S. Geological Survey senior resource scientist Chris Milly and physical scientist Krista A. Dunne have concluded. And they say the phenomenon is likely to accelerate.

"Less snow means less heat is reflected from the sun, creating a feedback loop known as the albedo effect, they say," reports Juliet Eilperin of The Washington Post. "The new findings are significant because about 40 million Americans living across the West depend on water from the Colorado River, which supports $1 trillion in economic activity each year. The water is shipped as far away as California’s Imperial Valley and central Arizona, where farmers use it to irrigate crops, as well as across the Rockies to supply drinking water for Colorado’s biggest cities."

Eliperin writes, "The region is poised to warm even more in the years ahead, Milly said, and it isn’t 'likely' that precipitation can compensate for these hotter and drier conditions," Comparing the Colorado River’s historic flow between 1913 and 2017 to future conditions, he added: 'That flow, we estimate, due to the warming alone would be reduced anywhere from 14 to 31 percent by 2050.' Colorado State University senior scientist Brad Udall, who has written two papers attributing half of the Colorado River’s lower flows to warming temperatures, said in a phone interview that researchers now 'have multiple lines of evidence pointing to a very similar number.' . . . Udall said of the new study, 'I would say eye-popping.'"

More jails and prisons offer medication-assisted treatment for drug addiction, a common malady of inmates

An inmate gets methadone. (Rhode Island Dept. of Corrections)

More prisons and jails are offering inmates medication-assisted treatment, with methadone and buprenorphine, to treat the prisoners' addiction to opioids, Christine Vestal of Stateline reports. "Research shows that MAT is at least twice as effective as abstinence-based treatment that does not include medications," she notes.

Vestal focuses on Rhode Island, which is doing more than any other state, she reports: There, inmates get strips of buprenorphine, often sold under the brand name Subutex, "under their tongues, administered by a nurse and double-checked by guards — with military precision," and are "strip-searched before returning to their cells" to make sure the drugs "aren’t diverted to black markets inside or outside the prison."

The National Institute on Drug Abuse estimates that about two-thirds of the country’s 2.3 million inmates are addicted to drugs or alcohol, "but only a small fraction of those who need treatment behind bars receives it," Vestal reports.

"The vast majority of the nation’s nearly 2,000 state and federal prisons and 3,100 county and municipal jails do not offer addiction treatment that includes any of the three medications — methadone, buprenorphine and Vivitrol — approved by the U.S. Food and Drug Administration. That’s changing, albeit slowly. An estimated 120 jails in 32 states and prison systems in 10 states now offer evidence-based treatment for opioid addiction, triple the number in 2018. . . . In addition, 10 states — California, Connecticut, Delaware, Hawaii, New Jersey, Pennsylvania, Rhode Island, Vermont, Washington and West Virginia — are offering MAT in state-run prisons."

That's a big change, Vestal notes: "In 2016, fewer than 40 prisons and jails offered methadone or buprenorphine for opioid addiction, both of which are narcotics and considered contraband by most corrections officials."

In Rhode Island, all inmates with an opioid addiction, whether they were previously in treatment or not, are offered a choice of one of the three FDA-approved medications, plus counseling.

"In most lockups, people who are using heroin, fentanyl or painkillers when they enter are forced into painful withdrawal," Vestal writes. "The simple detox or 'cold turkey' methods, even combined with motivational classes, fail 90 percent of the time, said Dr. Jody Rich, an addiction researcher at Brown University who studies Rhode Island’s correctional treatment program.

Democratic debate was a slugfest, but had rural resonance

L-R: Bloomberg, Buttegeig, Warren, Sanders, Biden, Klobuchar, Steyer (Photo via Real Clear Politics)

Last night, seven top Democratic candidates took the stage for a debate ahead of South Carolina's Saturday primary and Super Tuesday, when 14 states will vote. The debate quickly turned into a slugfest; Sen. Bernie Sanders of Vermont was a popular target, since he recently became the front-runner. Here are some of the highlights concerning issues with rural resonance:

Under pressure from former vice president Joe Biden, Sanders said his 1993 vote against the Brady Bill "was a bad vote," and notes that the National Rifle Association now gives his voting record a D-minus. "Sanders’ firearm votes in the past have reflected his constituency in rural Vermont," write Tim Marema and Adam Gorgio of The Daily Yonder, adding:

"Minnesota Sen, Amy Klobuchar said the way to get gun legislation passed is to work with moderate gun owners in parts of the nation where recreational gun use is more prevalent. 'I look at these [gun] proposals and say, do they hit my uncle Dick in the deer stand? They do not." Klobuchar said she wrote the part of the Violence Against Women Act that blocks unmarried domestic abusers from buying firearms (the "boyfriend loophole"), and is the only candidate who has carried Republican congressional districts while openly supporting an assault weapons ban.

"Biden was less conciliatory," the Yonder reports. "I want to tell you, if I’m elected, NRA, I’m coming for you, and gun manufacturers, I’m going to take you on and I’m going to beat you. I’m the only one who has done it," with the Brady Bill's assault-weapon ban and magazine-size restrictions, background checks and waiting periods, he said.

Sen. Elizabeth Warren of Massachusetts said gun-safety legislation can't pass, even with a majority vote, as long as the Senate employs the filibuster, and said that if Republicans continue to use it against a Democratic majority, Democrats should change the rules and eliminate it.

Former New York City Mayor Mike Bloomberg said he had founded the nation's biggest organization to prevent gun violence, Everytown for Gun Safety, which has a volunteer wing called Moms Demand Action. Bloomberg provides about one-third of Everytown's annual budget. He said he supports background checks, and implied that MDA had led to background-check laws in 20 states.

Pete Buttigieg, the former mayor of South Bend, Indiana, said he believes that the kind of weapons he had access to as a soldier in the Middle East should not be sold "anywhere near an American school or church or neighbor."

Billionaire philanthropist Tom Steyer said the problem isn't so much that Americans need to be convinced that there's too much gun violence; the real problem is that corporate lobbyists have too much influence in the government. "The gun manufacturers own the Senate of the United States," he said. "So even though more than 90 percent of Americans want mandatory background checks on every gun purchase, we can't get it through the Senate."

On other issues, Klobuchar was asked about affordable housing and education for minimum wage workers. She said it's important to take care of the Section 8 housing backlog and create incentives to build and pay for affordable housing. She said it's a huge rural problem, and that businesses sometimes can't locate in rural areas because there isn't enough housing.

A moderator noted that rural areas have populations that are older, sicker, and poorer than non-rural communities on average, and asked Klobuchar how she would ensure health-care accessibility in rural areas. Klobuchar said there is no "one size fits all" solution, and said she is the lead Democrat on a bill that would expand funding for critical-access hospitals and other rural health-care providers. She suggested making associate's degrees for some health-care jobs free, since rural areas especially will need more home-health workers and more. She also endorsed loan-forgiveness programs and expanded immigrant visas for health-care workers who agree to work in rural America.

Sanders said he supports debt forgiveness for health-care workers in under-served areas, and said Medicare for All would help expand rural coverage because it would remove the profit incentive.

CBS, the Congressional Black Caucus and Twitter hosted the debate in Charleston.

This item may be updated.

Ky. touts bill to rein in Medicaid pharmacy managers, whom rural, independent pharmacies blame for trouble and closure

Pharmacist Gregg Henry updates customers of his closed store. (Photo by Greg Eans, Owensboro Messenger-Inquirer)

The Kentucky Senate has passed a bill aimed at reining in the middlemen who decide who gets paid how much for drugs in Medicaid, a problem that advocates say is threatening independent rural pharmacies all over the country.

"We're going to be the first state in the country that is going to do something like this," the bill's sponsor, Sen. Max Wise, R-Campbellsville, told Melissa Patrick of Kentucky Health News. "There are going to be a lot of eyes on Kentucky." The bill is now in the state House.

Rosemary Smith of the Kentucky Independent Pharmacist Alliance, which represents 500 independent pharmacists, told Patrick, "This bill will allow us to stay open." Smith said she and her husband have been forced to close two of their drug stores because of low reimbursement rates from pharmacy benefit managers, who act as middlemen between insurance and drug companies; they determine what drugs are offered, how much is paid for the drug, and payments to pharmacists.

In Kentucky, each of the state's five Medicaid managed-care firms contracts with a PBM to manage the state's $1.7 billion-a-year prescription drug business. Wise's bill would require the state to hire a single PBM. CVS Health, an affiliate of the drugstore chain, which holds most of the state's current PBM business in contracts with manged-care firms, criticized the bill, Deborah Yetter reports for the Louisville Courier-Journal.

Gregg Henry told Renee Beasley Jones of the Owensboro Messenger-Inquirer that he was closing his pharmacy in Sacramento, Ky., after seven years because of the low reimbursements paid by the PBMs, which started in 2017. He said he lost $5,000 in January alone because of recent cuts.

"This little bitty pharmacy in this little bitty community stood up," Henry told Jones, in reference to at least two years of fighting against the PBMs. "I hope our martyrdom creates a wake-up call about the absolute necessity for the passage of this legislation."

Idaho Statesman investigation reveals some private contractors cheated the state on tests of road repairs

Here's a great example of watchdog journalism: The Idaho Statesman recently published an investigation revealing that private contractors meant to repair infrastructure were fleecing the state.

"Companies that are responsible for checking the quality of Idaho’s road materials have altered the results of their asphalt tests thousands of times, government documents show. Those changes may have allowed contractors that repair and build Idaho’s highway infrastructure to get bonus payments when they should have been penalized for substandard work — or even forced to tear up the asphalt and replace it," Audrey Dutton reports for the Statesman.

According to a Statesman analysis of four highway projects, the state paid contractors about $8 million, including $190,000 in bonuses, for asphalt whose test results were altered "dozens or hundreds of times," Dutton reports.

"For decades, Idaho has paid private contractors to repair and build the state’s vast system of highways, roads and bridges. They are trusted to be good stewards of taxpayer dollars and to ensure the state’s infrastructure is built to last and is safe for drivers," Dutton reports. "Most of Idaho’s tests are performed by private contractors, since the state cut back on resources it needed to run them in-house."

Tractor-trailers and farm equipment have become much larger over the past few decades, which causes increased wear and tear on the nation's roads. Since many of those road miles are in rural areas, states can pay disproportionate amounts of money to fix rural infrastructure. The bottom line: road upkeep is expensive enough without the added cost of shady contractors.

Supreme Court hears arguments about pipeline; justices in majority seem sympathetic to energy companies

Atlantic Coast Pipeline proposed route (Associated Press map)

The U.S. Supreme Court heard arguments Monday about whether a lower court was right to toss a key permit needed for the proposed Atlantic Coast Pipeline to cross under the Appalachian Trail. The court seems poised to rule for the natural-gas pipeline developers; most justices expressed skepticism about the lower court's ruling, Denise Lavoie reports for The Associated Press.

In 2018, the Richmond-based Fourth U.S. Circuit Court of Appeals "found the U.S. Forest Service did not have the authority to grant a right-of-way to allow the pipeline to cross beneath the Appalachian Trail in the George Washington National Forest" on the Virginia-West Virginia border, Lavoie reports. "The Fourth Circuit found that the 1920 Mineral Leasing Act allows rights-of-way for pipelines on federal land, except for land in the National Park System." The court found that the trail is a unit of the system, so the service has no the authority to approve a right-of-way. Only Congress can approve such a crossing, the environmental groups argued.

But conservative justices in the Supreme Court's 5-4 majority were hesitant about upholding the appeals court's ruling, and "expressed concern that concluding that no federal agency can grant easements for pipeline projects on lands crossed by the trail within national forests could erect a roadblock to energy infrastructure projects," Lavoie reports.

Attorney Michael Kellogg, who represents the environmental groups, noted that 55 pipelines run under the Appalachian Trail, 19 of them laid on federal land before the Appalachian Trail was designated as a national scenic trail under the National Trails System Act in 1968, Lavoie reports.

"The narrow question before the Supreme Court is whether the Forest Service has the authority to grant rights-of-way through lands crossed by the Appalachian Trail within national forests," Lavoie reports. Lead pipeline developer Dominion Energy and the federal government "say the Trails System Act did not transfer lands crossed by the trail to the National Park Service. They argue that although the Park Service is charged with overall administration of the trail, the actual lands crossed by the trail within national forests remain under the jurisdiction of the Forest Service."

Local journalism, or its absence, helps cover and shape Atlantic Coast Pipeline development, journalist reports

As the U.S. Supreme Court mulls a pivotal case involving the construction of the proposed Atlantic Coast Pipeline, one journalist considers the role local journalism can play in shaping local opinions about pipeline construction.

Many of the North Carolina, Virginia, and West Virginia counties the pipeline will cross are poor and rural, and some have large minority populations. Many do not have a strong local-news ecosystem, either because metropolitan papers have cut back coverage or local newspapers have shuttered, never existed or fell down on the job, Lyndsey Gilpin writes for the Columbia Journalism Review. Gilpin is the founder and editor of Southerly, an independent media organization that covers ecology, justice and culture in the American South.

According to the University of North Carolina's Penny Abernathy's research on news deserts, "in about half of the 25 counties along the Atlantic Coast Pipeline route, print news comprises a single weekly paper; several weekly or daily papers cover more than one county," Gilpin reports.

When the pipeline was first proposed in 2014, local and regional newspapers reported on it (some still do) and several nationwide news publications covered it, but comprehensive coverage has mostly faded as the process wears on. Local and regional news coverage is often the only way such places receive any press attention; national media mostly tends to "parachute in to cover major updates or catastrophes or if they need a tie-in to President Trump’s policies—a dynamic that can perpetuate inaccurate stereotypes about these places," Gilpin writes.

Meanwhile, the absence of local news media "leaves ample space for powerful campaigns by [Duke Energy] and [Dominion Energy], the pipeline’s developers and buyers of its natural gas, as well as industry-aligned lobbyists and politicians, to shape the pipeline narrative," Gilpin writes. "Another result is misinformation and confusion about the status of a massive energy project that affects tens of thousands of people, several endangered species, and a variety of fragile ecosystems. The number of permanent jobs the pipeline is estimated to create varies, depending on whom you speak with. In some cases, property owners have been caught unaware of their rights or legal options when Dominion came knocking to claim eminent domain."

Local reporters who would like to do in-depth reporting on the pipeline often have little time and few resources to do so, though projects like ProPublica's Local Reporting Network have helped, Gilpin writes. Most local reporters only have enough bandwidth to focus on reaction stories.

Independent journalist Mason Adams of the Roanoke area, who has covered pipelines for various news outlets over the past few years, said such coverage is complicated, and local reporters need more training to deal with Freedom of Information Act requests, regulatory agencies, major companies, and court reporting. "Smaller papers can’t set aside an entire body to cover this, much less over five to six years," Adams told Gilpin.

Researchers find the little brown bat may be evolving to become more resistant to deadly white-nose syndrome

A healthy little brown bat (U.S. Fish and Wildlife Service photo)

University of Michigan biologists have discovered the first genetic evidence of resistance in bats to white-nose syndrome, a fungal disease that has killed millions of the flying mammals in North America, according to a newly published study.

"The study involved northern Michigan populations of the little brown bat, one of the most common bats in eastern North America prior to the arrival of white-nose syndrome in 2006. Since then, some populations of the small, insect-eating bat have experienced declines of more than 90 percent," Jim Erickson reports for University of Michigan News. "UM researchers collected tissue samples from wild little brown bats that survived the disease, as well as individuals killed by the fungal pathogen. They compared the genetic makeup of the two groups and found differences in genes associated with regulating arousal from hibernation, the breakdown of fats and echo-location."

Translation: Bats that are genetically prone to be a little fatter or sleep more deeply may be less susceptible to the disease. The disease kills bats two ways: When the fungus grows on them while they're hibernating, it causes them to use twice as much energy as normal to maintain bodily functions, and sometimes they waste away before making it to spring. The fungus also kills bats when it irritates them so much that they wake up during hibernation and, disoriented, leave the cave in the middle of the winter and starve.

The rapid genetic changes in those areas suggest the bats are evolving due to natural selection. As bats with these genes reproduce, more bats could survive the disease, say the authors.

"While the study was small—involving tissue samples from 25 little brown bats killed by white-nose syndrome and nine bats that survived the disease—the authors say their sample size is large enough to detect genetic changes driven by natural selection," Erickson reports. "A larger follow-up study is underway, expanding both the number of bats and the areas affected by the disease, to develop a fuller picture of adaptive change that may be key to the species’ survival."

Bats play an important role in ecosystems and contribute at least $3 billion annually to the U.S. agriculture economy by pollinating crops, dispersing seeds and keeping insect populations down. But white-nose has decimated bat populations in at least 33 states and experts say some bat species may go extinct because of it.

Kids in rural town learn to administer Narcan (naloxone)

Nolan Loveday, 10, examines a Narcan dose during a
training course. (New York Times photo by Mike Belleme)

In an effort to fight the opioid epidemic, a mostly rural Tennessee county is teaching children as young as six years old to administer a nasal spray that can revive an overdose victim.

Like many other places in America, the area has been hit hard by the opioid epidemic. "In Carter County, where 56,000 people live in a cluster of small cities and rural towns on the North Carolina border, nearly 60 people have died from opioid overdoses since 2014. That year, 8.1 million painkiller prescriptions were written in Tennessee, more than the state’s population of about 6.5 million," Dan Levin reports for The New York Times.

The high death told led county health officials to embrace the "practical — if radical — strategy" of teaching children how to reverse an overdose. In the past three years, the Carter County Drug Prevention Coalition "has given Narcan training to an estimated 600 young children and teenagers in after-school programs, babysitting classes and vaping cessation courses," Levin reports. "Some of the young people have in turn trained their peers and taken a leading role in distributing Narcan at community events, like a back-to-school bash last fall where one child gave out 70 doses." At least 100 children have asked the coalition for additional doses, usually because they had already administered the doses they were given. Narcan is the brans name for naloxone.

Carter County (Wikipedia map)

However, many locals in the socially conservative community have opposed the measure, including school board members and police officers. Many schools and counties have rejected drug prevention educators' requests to expand the program in other schools or counties in East Tennessee, Levin reports.

"Lots of people say children don’t need to think about these things," one such educator, Jillian Reece, told Levin. "But I’d rather a kid should go through the trauma of giving Narcan than see their parent die."

Honored energy and environmental reporter Ken Ward Jr. follows his editor out the door at Charleston Gazette-Mail

Ken Ward Jr.

The Charleston Gazette-Mail, the main finder of facts in one of the nation's most rural states, has lost two national standout journalists in the last five days. On Thursday, Executive Editor Greg Moore announced that his job had been eliminated "unexpectedly," and this morning top reporter Ken Ward Jr. tweeted that today is his last day at the paper: "After 28 years, I've decided it's time for new adventures and different challenges."

When Moore made his announcement, Ward called the decision "short-sighted" and said Moore "has led this paper through a difficult transition, and was guiding us toward a strong future." Kristen Hare of The Poynter Institute got a memo Moore sent his staff, saying in part, "I hope the people newly in charge of the newsroom have the sense to continue letting this newsroom evolve, and letting everyone in the newsroom have a voice, and relying on the vast knowledge and experience that has been accumulated here."

Hare writes, "New Regional Executive Editor Lee Wolverton had no comment. Poynter has reached out to other executives with HD Media, the Gazette-Mail’s owner, for comment." In a tweet, Ward thanked HD Media owner Doug Reynolds "and other local investors who bought our paper our of bankruptcy and supported so many of our efforts." Reynolds is from Huntington, where he earlier bought The Herald-Dispatch. He is in the natural-gas industry, which is rivaling the shrunken coal industry for influence in West Virginia, and has been a major focus for Ward and the Gazette-Mail in their reporting partnership with Pro Publica. Reynolds has complimented Ward's work.

Ward has received a MacArthur Foundation fellowship and the Tom and Pat Gish Award for courage, integrity and tenacity in rural journalism, given by the Institute for Rural Journalism and Community Issues, publisher of The Rural Blog.  For more on him, go here. A 2011 story is here.

New federal hemp regulations would make it harder for farmers to prove their plants aren't marijuana

"New federal regulations would make it harder for hemp growers to prove their plants are not marijuana, in what could be a major setback to a promising industry legalized just two years ago, farmers and state officials say," Sophie Quinton and April Simpson report for Stateline.

When the 2014 Farm Bill legalized pilot programs for hemp production, each state set its own hemp testing standards to ensure that the crops contained less than 0.3 percent tetrahydrocannabinol, the psychoactive ingredient that legally distinguishes hemp from marijuana. Nationwide hemp cultivation was approved in the 2018 Farm Bill, but the measure included little direction for federal or state regulation and regulators have been playing catchup since then, Quinton and Simpson report.

In October the U.S. Department of Agriculture unveiled federal THC testing standards that are more rigorous and with a shorter time frame than those used in many states' pilot programs. "It also gives farmers less wiggle room to salvage crops that grow hot, or above the 0.3% THC mark," Quinton and Simpson write. "Now states are scrambling to adapt, and farmers are worrying they’ll face a higher risk of having to destroy crops that test 'hot' as marijuana."

Several state agriculture officials told Stateline that more crops could test hot under the proposed rule. "In Maine, for instance, none of the more than 2,000 acres tested last year were considered hot. But under the USDA’s more stringent testing standards, more than a fourth of the crop would have failed, according to State Horticulturalist Gary Fish," Quinton and Simpson report.

An interim USDA rule goes into effect Nov. 1, but the final rule may not be issued until after the 2021 growing season, which gives state officials more time to lobby for a change. In the meantime, states like Kentucky and Vermont that had pilot programs can extend those programs (and their testing standards) through this growing season. But at least 30 states will have to adapt their rules to match the stricter USDA standards right away, Quinton and Simpson report.

Trump says farmers will get more trade aid if they need it, after USDA predicts China won't buy as much as promised

President Trump promised American farmers more trade bailout money if they need it. His tweet on Friday may have been in reaction to Department of Agriculture economists' prediction that China will not buy as much agricultural goods as promised in the recent "phase one" trade agreement.

At the USDA's annual Agricultural Outlook Forum on Friday, the department's chief economist, Robert Johansson, projected that China would buy about $14 billion in U.S. farm products by the end of Sept. 30. China had promised in the trade deal to buy about $40 billion this year though. Johansson told The Washington Post that some of the discrepancy came because he was talking about the fiscal year, which meant China's purchases for October through December weren't counted in his estimates. But at the same event, Agriculture Secretary Sonny Perdue said that he remains concerned about enforcing China's purchase commitments, and said that variables like the coronavirus and Asian swine flu, which has devastated China's pork industry, made predictions difficult.

Agriculture Undersecretary Ted McKinney said at the forum that Trump's tweet "was a surprise to us" but said the department will support his decision, Chuck Abbott reports for Successful Farming.

Trump tweeted in all capital letters, "If our formally targeted farmers need additional aid until such time as the trade deals with China, Mexico, Canada and others fully kick in, that aid will be provided by the federal government, paid for out of the massive tariff money coming into the USA!"

"He also added, erroneously, that the money for the aid would come from tariffs his administration has slapped on billions of dollars of imported goods. Economists have shown that U.S. businesses and consumers are paying those duties, rather than China," Ryan McCrimmon reports for Politico. "Trump’s dangling of extra bailout money stands in contrast to his recent boasts that farmers should start buying more land and 'bigger tractors' to keep up with the historic boom that he promised his new trade agreements would deliver."

The tweet also seemingly flies in the face of Perdue's repeated statements that farmers shouldn't expect any more trade aid, now that the U.S. and China have reached a deal, McCrimmon reports.

With spring planting just around the corner (or already starting), farmers may factor the possibility of more aid in their decisions. Aid last year was tied to acres planted, so farmers could be encouraged "to plant more land this spring than would otherwise be justified," Abbott reports.

Newspaper in Marfa, Texas, opens a cafe and bar to help cover its operating costs and engage with its audience

The Sentinel café and The Big Bend Sentinel weekly operate out of the same building. (NYT photo by Jessica Lutz)

The Big Bend Sentinel in Marfa, Texas, is nearly a century old, but its new owners aren't shy about innovation: to grow closer to locals and help the paper make more money, they moved operations to a new building and opened up a café, The Sentinel, that has become a major local watering hole in the town of about 2,000, Sasha von Oldershausen reports for The New York Times.

New York transplants Maisie Crow and Max Kabat bought the paper last year after being approached by Robert and Rosario Halpern, who had published the paper for 25 years. The paper was sustaining itself on ad sales and subscriptions, but just barely. The new owners "hoped to bring locals closer, physically, to the institution covering their hometown," von Oldershausen reports. So they bought an older building, renovated it, and turned it into a café/bar with a small newspaper office attached in the back. They rent the kitchen space to local cooks, rent the space out for events, and otherwise make their money selling drinks.

Marfa, in Presidio County, Texas
(Wikipedia ma

The newspaper and the café exist in a weird legal and ethical space: on paper, the newspaper and the café are legally separate entities, even though they're in the same building. That's because in Texas, any business that serves alcohol is subject to warrantless search from law enforcement, and the owners didn't want to put the newspaper at risk. And though the café hosts public events, they recently turned down a political candidate's request to rent the space because they worried it might be seen as an endorsement, von Oldershausen reports.

The Sentinel's two full-time reporters sometimes work out of the café, which functions as a local watering hole. Managing editor Abbie Perrault told von Oldershausen: "It’s a great way to keep my finger on the pulse and get new leads and find stories."

Kabat and Crow have made changes to the paper too. They've expanded the Sentinel's digital platform, driving a 7 percent bump in online traffic, and increased its photographic coverage. "At the newspaper’s sister publication, The International, which the couple also owns and which serves the largely Spanish-speaking neighboring border town of Presidio, every article is now translated into Spanish. They added a crossword puzzle and Sudoku to both papers, too," von Oldershausen reports. "The newspapers still sell ads, which account for the majority of revenue. But with additional income from private events and day-to-day drink sales, the publishers have been able to keep yearly subscription costs steady: $50 for area residents and $60 for anyone outside."

Scanty ambulance access in rural Pennsylvania illustrates nationwide difficulties in sustaining emergency services

Union City in Erie County, Penn.
(Wikipedia map)

An incident last December in Erie County, Pennsylvania, illustrates the growing difficulty in accessing emergency services in rural areas across the nation. Someone called 911 in Union City, pop. 3,320, but at least three nearby volunteer fire departments were unable to crew an ambulance, so 51 minutes later the 911 center canceled the alarm and said the caller was going to the hospital in a private vehicle, Kris Mamula reports for the Pittsburgh Post-Gazette. Last year, the Union City Fire Company couldn't provide an ambulance crew for 200 of the 710 total calls received.

"Problems recruiting first responders, rising operating costs and Medicare reimbursement that hasn’t kept pace with expenses are stressing emergency medical services throughout rural Pennsylvania," Mamula reports. "Outside of bigger cities like Pittsburgh, emergency medical service is not supported by municipal tax money. That leaves the vast majority of nonprofit ambulance services reliant upon billing for care to keep their trucks on the road and staffed around the clock."

Medicare pays medical providers, including ambulance services, according to a set payment list. "To set its rates, Medicare is surveying a number of ambulance services to determine average costs," Mamula reports. "Hospitals are required to file cost reports for providing various services. Medicare payments are typically based on a percentage of costs, with hospitals generally receiving 12 percent."

The Union City fire department hired two firefighters/EMS responders last year with combined salaries of $75,000. The city government gives the department $24,000 a year to help, but that's only a third of the money needed. "The EMS math tightrope is similar across many such services in Western Pennsylvania. Most of Union City’s ambulance patients have Medicaid or Medicare insurance coverage — typical for EMS services — which pay $160 and about $400 per call respectively," Mamula reports. "A new ambulance can cost between $150,000 and $200,000. And new power stretchers — which help load overweight patients while cutting worker’s compensation injury claims — cost between $60,000 and $70,000 each. The latest heart monitor costs about $90,000."

Union City EMS volunteer Larry Obert, 79, said a tax increase was the best long-term solution. "It’s a nightmare," Obert told Mamula. "Somebody has to subsidize it." Fire department leaders agreed recently to ask the local government to fund an eight-person EMS crew that could respond 24/7, at a cost of about $326,000. Raising that kind of money would require a tax hike, according to the borough council president. But a tax increase could really hurt in one of the poorest towns in the state.

The fire department tries to defray costs by selling annual memberships at $40 each; members don't have to pay any remaining balances on ambulance bills remaining after the insurer pays its portion. But without the requested extra funding from the local government, the fire department would have to shut down its EMS service by June. It opened the service in 2016 after a previous volunteer ambulance service shuttered, Mamula reports.

Larger private EMS services can sometimes step in when small services like Union City's close down, but "experts say big ambulance services aren’t immune to the forces threatening emergency services. Pittsburgh EMS, for example, answers some 64,600 calls a year, yet is expected to run an $11.4 million operational deficit in 2020. Tax money will make up the shortfall."